Health inspection·September 26, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility did not document a prescribed order for oxygen therapy on time and did not ensure oxygen therapy was delivered as prescribed for one (Resident #23) out of one sample resident who has a primary diagnosis of Chronic Obstructive Pulmonary Disease. This was evidenced by the absence of a written order for oxygen therapy in the Electronic Medication Administration Records (EMAR). During an initial screening observation on 09/23/2025 at 8:30 AM, revealed Resident #23 in bed with eyes closed, receiving oxygen at two liters per minute (Lpm) via nasal cannula (NC); the oxygen tubing was positioned on the resident's forehead. At 8:34 AM, the surveyor requested Registered Nurse (RN) Staff A to come to the resident's room. Staff A, RN assessed the resident, washed her hands, donned gloves, and repositioned the oxygen tubing in the resident's nostrils.Observations on 09/24/2025 at 8:25 AM and on 09/25/2020 at 7:00 AM, noted Resident #23 in bed with eyes closed, displaying no signs of distress, and receiving oxygen at 2 Lpm via NC.Review of Resident #23's medical records showed the resident was initially admitted on [DATE] and readmitted [DATE]. Clinical diagnoses included Chronic Obstructive Pulmonary Disease (COPD).Review of the Physician's Orders Sheet for September 2025 revealed that starting from 09/24/25, there were orders for Resident #23 to receive oxygen at two liters per minute (Lpm) via nasal cannula continuously every shift for shortness of breath.A record review of Resident #23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: Section C for Cognitive Patterns documented a Brief Interview for Mental Status Score (BIMS) as unable to determine. Section GG for Functional Status documented dependence for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments documented: None received.A review of Resident #23's Care Plan Reference dated 08/25/25 indicated that the resident is at risk for difficulty breathing related to COPD. The plan expects the resident to maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include administering medication/inhalers/nebulizers as ordered, encouraging adequate rest periods between tasks/activities, monitoring for signs and symptoms of respiratory distress, and reporting to the physician any increased respirations, decreased pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, or skin color changes to blue/grey. Additionally, it includes maintaining a clear airway by encouraging the resident to clear their own secretions with effective coughing, suctioning as ordered/required to clear secretions if necessary, using pain management as appropriate, and monitoring/documenting side effects and effectiveness.In an interview on 09/23/2025 at 8:37 AM, RN Staff A reported that the resident frequently removes his oxygen tubing. She checks on the resident often throughout her shift to ensure he is okay. She started her shift around 8:00 AM and had checked on the resident at the start of her shift; he was in no distress, and Page 1 of 2 105711 105711 09/26/2025 Shoreside Health and Rehabilitation Center 201 NE 112th Street Miami, FL 33161

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his tubing was in place.On 09/25/2025 at 2:55 PM, Staff A, RN revealed that the resident has been on oxygen therapy since last Friday, 09/19/25.In an interview on 09/25/25 at 3:15 PM, the Director of Nursing (DON) stated that she was not aware the resident did not have an order for the oxygen therapy he was receiving. The records show the order for the resident started on 09/24/25. The order states oxygen at 2 Lpm via NC continuously. She completed an in-service with all the nursing staff regarding checking all residents' orders for accuracy and instructed the nursing staff to make purposeful rounds to check on the resident daily.On 09/26/25 at 8:31 AM, the DON revealed that after further reviewing the resident's records, on 09/19/25, the 3:00 PM to 11:00 PM supervisor received an order from the resident's physician for oxygen at 8 liters per minute because the resident was in respiratory crisis and labs were ordered. The labs were completed, and results sent to the physician; new orders were given for oxygen at 2 liters per minute via nasal cannula on 09/19/25. The orders were not placed into the electronic medical records system until 09/24/25.A review of the facility policy and procedure titled Oxygen Therapy with a revision date of January 2025 states the purpose of this procedure is to provide guidelines for safe oxygen administration. It specifies verifying that there is a physician's order for this procedure and reviewing the physician's order or facility protocol for oxygen administration. 105711 Page 2 of 2